What is the appropriate management for a hypertensive patient with peeling skin on the palms and feet?

Evaluation and Management of Palmoplantar Skin Peeling in a Hypertensive Patient

Immediate Priority: Rule Out Drug-Induced Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

This patient requires urgent evaluation to exclude Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN), a potentially life-threatening drug reaction that characteristically involves the palms and soles prominently. 1, 2

Critical Assessment Steps

Examine for features that distinguish SJS/TEN from benign causes:

• Assess for cutaneous pain - This is a prominent early feature in SJS/TEN and should immediately alert you to incipient epidermal necrolysis 1, 2
• Check for mucosal involvement - Erosive and hemorrhagic mucositis of the eyes, mouth, nose, or genitalia is usually an early feature of SJS/TEN 1, 2
• Evaluate the rash pattern - SJS/TEN typically begins on the upper torso, proximal limbs, and face before spreading, with prominent palmoplantar involvement 1, 2
• Test for Nikolsky sign - Gentle lateral pressure causing epidermal detachment indicates epidermal necrolysis, though this is not specific for SJS/TEN 1, 2
• Look for atypical target lesions - Dark red center surrounded by pink ring, or purpuric macules that are tender to touch 1, 2

Medication Review for SJS/TEN Risk

Review all antihypertensive medications started within the past 8 weeks, as drug-induced cytotoxic T lymphocyte activation is the primary mechanism of SJS/TEN 1:

• Common culprits include sulfonamides, anticonvulsants, allopurinol, and NSAIDs 1
• If SJS/TEN is suspected, immediately discontinue the offending medication and refer for emergency hospitalization 1

Alternative Diagnosis: Acitretin-Related or Retinoid Dermatitis

If the patient is not on retinoids but the presentation suggests retinoid-like effects, consider:

• Thinning, redness, and scaling of skin particularly on palms and soles is a characteristic side effect of acitretin and other retinoids 1
• This causes increased sensitivity and fragility making walking and grasping objects difficult 1
• However, this patient is not described as being on retinoids, making this less likely 1

Most Likely Diagnosis: Acral Peeling Skin Syndrome or Benign Palmoplantar Desquamation

If SJS/TEN features are absent and the patient has painless peeling limited to acral surfaces:

• Acral peeling skin syndrome presents as spontaneous asymptomatic peeling limited to palms and soles 3
• This is typically a chronic condition with abnormal keratohyalin granules causing separation in the stratum corneum 3
• Peeling skin syndrome can involve palms and soles in some variants 4

Management Algorithm

Step 1: Emergency Triage (Complete Within 1 Hour)

• If ANY of the following are present, arrange immediate hospital transfer: 1, 2
  • Cutaneous pain or tenderness
  • Positive Nikolsky sign
  • Mucosal involvement (oral, ocular, genital erosions)
  • Atypical target lesions or purpuric macules
  • Systemic symptoms (fever, malaise)

Step 2: Hypertension Management Considerations

Optimize blood pressure control while investigating the skin condition:

• Current blood pressure status should be assessed with repeated measurements in both arms 5
• For this 48-year-old hypertensive male, target BP should be <130/80 mmHg if he has diabetes, chronic kidney disease, or 10-year cardiovascular risk ≥10% 1, 5
• Avoid medication changes that could confound the dermatologic diagnosis until the cause of peeling is determined 1

Important caveat: Beta-blockers and calcium channel blockers are NOT contraindicated in psoriasis patients despite older concerns, and there is no evidence supporting avoidance of particular antihypertensives based on dermatologic conditions 1

Step 3: Dermatologic Workup (If SJS/TEN Excluded)

For painless palmoplantar peeling without systemic features:

• Obtain skin biopsy from the edge of peeling area before and potentially after water immersion 3
• Light and electron microscopy to evaluate for abnormal keratohyalin granules and keratin filament aggregation 3
• Consider fungal culture and KOH preparation to exclude tinea manuum/pedis
• Review for contact dermatitis exposures (occupational, household chemicals)

Step 4: Symptomatic Management

While awaiting definitive diagnosis:

• Apply emollients and barrier creams to affected areas
• Avoid irritants and excessive water exposure
• Consider low-potency topical corticosteroids if inflammatory component present
• Do NOT use high-potency topical steroids on palms/soles without dermatology consultation, as this can mask serious conditions

Critical Pitfalls to Avoid

• Never dismiss palmoplantar involvement as "just dry skin" in a patient on multiple medications - SJS/TEN prominently involves palms and soles 1, 2
• Do not attribute skin changes to hypertension itself - hypertension does not cause palmoplantar peeling 1
• Avoid rapid antihypertensive medication changes without first establishing the dermatologic diagnosis, as this may confound causality assessment 5
• Do not delay referral if any features suggest SJS/TEN, as mortality increases with delayed recognition and continued drug exposure 1